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<!------------------------------------------------------------------------------------------------------------------------------------
	HTML below this line.
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<!-- Login Page -->
<div id="login" data-role="page" data-title="login">
    <div id="Header" data-theme="a" data-role="header" data-position="fixed">
        <h1>Homeless Registry App</h1>
        <a data-role="button" href="#help_dialog" data-rel = "dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
      <div id="loginForm">
        User Name:<br/>
        <input type="text" id="usernameInputField" autocorrect="off" autocapitalize="off" /><br />
        Password:<br/>
        <input type="password" id="passwordInputField" autocorrect="off" autocapitalize="off"/><br/>    
        <a href="#ConsentPage" data-role="button"id="loginButton" >Login</a>
      </div>
    </div>
</div>
    
<!-- Help Dialog -->
<div id="help_dialog" data-role="page" data-title="helpdialog">
    <div data-role='header' data-position='inline' data-theme='a'>
        <h1> </h1>
    </div>
    
    <div id="help_content" data-role="content">
        Content for the Help Dialog will go here.
    </div>
</div>

<!-- Consent Page -->
<div id="ConsentPage" data-role="page" data-title="consent">
    <div id="Header" data-theme="a" data-role="header" data-position="fixed">
        <a data-role="button" href="#login" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <h4>
            Consent
        </h4>
        <a data-role="button" href="#help_dialog" data-rel = "dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Please read the following to the participant.
        </h4>
        <h5>
            We are here today to talk to you about your housing and service needs. If you give us permission, we will ask you some questions today for about 10 minutes. These questions are about your health and housing. By participating in the interview you give permission to [TBD] to provide your information to authorized agencies for the purpose of improving services and housing in this community. Some of the questions we ask might make you feel uncomfortable or be upsetting. If you feel uncomfortable or upset during the interview, you may ask the interviewers to take a break or to skip any of the questions. The information you share during the interview may be stored in a secure database and also be shared with outreach workers and case managers who will follow up with you for services. All of your information will be kept secure and individuals who will see it have signed confidentiality waivers and will not share your information. At any time, you can request that your information be removed from the database. We will give you a $5 food card at the end of the interview to thank you for your time. No one will be upset or angry if you decide not to be interviewed today.
        </h5>
        <a data-role="button" data-theme="b" href="#SignaturePage" data-icon="check" data-iconpos="left">
            Continue
        </a>
    </div>
    <div data-theme="a" data-role="footer" data-position="fixed">
        <span class="ui-title">
        </span>
    </div>
</div>
    
<!-- Signature Page -->
<div id="SignaturePage" data-role="page" data-title="signature">
    <div id="Header" data-theme="a" data-role="header" data-position="fixed">
        <a data-role="button" href="#ConsentPage" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <h4>
            Signature
        </h4>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Please read the following to the participant.
        </h4>
        <h5>
            Your signature (or mark) indicates that you have read (or been read) the information provided on the consent form, have gotten answers to your questions, and have freely chosen to be interviewed. By agreeing to be interviewed, you are not giving up any of your legal rights.
        </h5>
        <a data-role="button" data-theme="b" href="#InterviewInfoPage" data-icon="check" data-iconpos="left">
            Continue
        </a>
    </div>
    <div data-theme="a" data-role="footer" data-position="fixed">
        <span class="ui-title">
        </span>
    </div>
</div>
    
<!-- Interview Info Page -->
<div id="InterviewInfoPage" data-role="page" data-title="interviewinfo">
    <div data-theme="a" data-role="header">
        <h3>
            Interview Info
        </h3>
        <a data-role="button" data-rel="back" href="#SignaturePage" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <div id=identifier_i>
           <h4>
              Identifier: 123-0
           </h4>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput1">
                    1. INTERVIEWER'S NAME
                </label>
                <input name="" id="textinput1" placeholder="John Doe" value="" type="text"  />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput2">
                    2. AGENCY NAME
                </label>
                <input name="" id="textinput2" placeholder="Agency A" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    Interviewer is a:
                </legend>
                <input id="radio1" name="" value="radio1" type="radio" />
                <label for="radio1">
                    STAFF
                </label>
                <input id="radio2" name="" value="radio2" type="radio" />
                <label for="radio2">
                    VOLUNTEER
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput5">
                    3. DATE
                </label>
                <input name="" id="textinput5" placeholder="2012-12-02" value="" type="text"  />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput6">
                    4. TIME
                </label>
                <input name="" id="textinput6" placeholder="16:30:00" value="" type="text"  />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput7">
                    5. LOCATION
                </label>
                <input name="" id="textinput7" placeholder="Georgia Tech Student Center" value="" type="text" />
            </fieldset>
        </div>
        
	<div id=map_canvas></div>

        <a data-role="button" data-theme="b" href="#ParticipantInfoPage" data-icon="check" data-iconpos="left" onclick="updateInterviewInfoPage()">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Participant Info Page -->
<div id="ParticipantInfoPage" data-role="page" data-title="participantinfo">
    <div data-theme="a" data-role="header">
        <h3>
            Participant Info
        </h3>
        <a data-role="button" data-rel="back" href="#InterviewInfoPage" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <div id=identifier_p>
           <h4>
              Identifier: 123-0
           </h4>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput8">
                    6. In what language do you feel best able to express yourself?
                </label>
                <input name="" id="textinput8" placeholder="English" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput9">
                    7. FIRST NAME
                </label>
                <input name="" id="textinput9" placeholder="Peter" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput10">
                    8. LAST NAME
                </label>
                <input name="" id="textinput10" placeholder="Chan" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput11">
                    9. NICKNAME
                </label>
                <input name="" id="textinput11" placeholder="Victor" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput12">
                    10. DOB
                </label>
                <input name="" id="textinput12" placeholder="1989-01-01" value="" type="date" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput13">
                    11. Social Security Number
                </label>
                <input name="" id="textinput13" placeholder="1111111111" value="" type="text" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    12. Has Consented to Participate:
                </legend>
                <input id="radio4" name="" value="radio4" type="radio" />
                <label for="radio4">
                    YES
                </label>
                <input id="radio5" name="" value="radio5" type="radio" />
                <label for="radio5">
                    NO
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q13" data-icon="check" data-iconpos="left" onclick="updateParticipantInfoPage()">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q13 -->
<div id="Q13" data-role="page" data-title="q13">
    <div data-theme="a" data-role="header">
        <h3>
            Housing History
        </h3>
        <a data-role="button" data-rel="back" href="#ParticipantInfoPage" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <div id=identifier_Q13>
           <h4>
              Identifier: 123-0
           </h4>
        </div>
        <h4>
            Please read to the participant:
        </h4>
        <h5>
            OK, first I'm going to ask you a few questions about your housing history...
        </h5>
        <h4>
            13. What is the total length of time you have lived on the streets or shelters?
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput14">
                    # of years
                </label>
                <input name="" id="textinput14" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput15">
                    # of months
                </label>
                <input name="" id="textinput15" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q14-15" data-icon="check" data-iconpos="left" onclick="updateQ13()">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q14-15 -->
<div id="Q14-15" data-role="page" data-title="q14-15">
    <div data-theme="a" data-role="header">
        <h3>
            Housing History
        </h3>
        <a data-role="button" data-rel="back" href="#Q13" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <div id=identifier_Q14-Q15>
           <h4>
              Identifier: 123-0
           </h4>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput16">
                    14. In the past three years, how many times have you been homeless and then housed again?
                </label>
                <input name="" id="textinput16" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    15. Where do you sleep most frequently?
                </legend>
                <input id="radio6" name="" value="Shelter" type="radio" />
                <label for="radio6">
                    Shelter
                </label>
                <input id="radio7" name="" value="Outside (street, camp, park)" type="radio" />
                <label for="radio7">
                    Outside (street, camp, park)
                </label>
                <input id="radio8" name="" value="Car/Van/RV" type="radio" />
                <label for="radio8">
                    Car/Van/RV
                </label>
                <input id="radio9" name="" value="Someone else's place" type="radio" />
                <label for="radio9">
                    Someone else's place
                </label>
                <input id="radio10" name="" value="Other" type="radio" />
                <label for="radio10">
                    Other
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput17">
                    If other, please specify:
                </label>
                <input name="" id="textinput17" placeholder="" value="" type="text" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q16" data-icon="check" data-iconpos="left" onclick="updateQ14and15()">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>

<!-- Q16 -->
<div id="Q16" data-role="page" data-title="q16">
    <div data-theme="a" data-role="header">
        <h3>
            Housing History
        </h3>
        <a data-role="button" data-rel="back" href="#Q14-15" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <div id=identifier_Q16>
           <h4>
              Identifier: 123-0
           </h4>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    16. Where did you live prior to becoming homeless? (location of last permanent residence)
                </legend>
                <input id="radio11" name="" value="This city" type="radio" />
                <label for="radio11">
                    This city
                </label>
                <input id="radio12" name="" value="This region" type="radio" />
                <label for="radio12">
                    This region
                </label>
                <input id="radio13" name="" value="Another place in GA" type="radio" />
                <label for="radio13">
                    Another place in GA
                </label>
                <input id="radio14" name="" value="Location outside of GA" type="radio" />
                <label for="radio14">
                    Location outside of GA
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput18">
                    If not this city or region, please specify town name or zip code:
                </label>
                <input name="" id="textinput18" placeholder="" value="" type="text" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q17" data-icon="check" data-iconpos="left" onclick="updateQ16()">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q17 -->
<div id="Q17" data-role="page" data-title="q17">
    <div data-theme="a" data-role="header">
        <h3>
            Housing History
        </h3>
        <a data-role="button" data-rel="back" href="#Q16" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div id="checkboxes1" data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    17. How did you arrive at this location (where you are sleeping)? (select all that apply)
                </legend>
                <input id="checkbox1" name="" type="checkbox" />
                <label for="checkbox1">
                    Bus
                </label>
                <input id="checkbox2" name="" type="checkbox" />
                <label for="checkbox2">
                    MARTA
                </label>
                <input id="checkbox3" name="" type="checkbox" />
                <label for="checkbox3">
                    Drove
                </label>
                <input id="checkbox4" name="" type="checkbox" />
                <label for="checkbox4">
                    Rode in someone else's car
                </label>
                <input id="checkbox5" name="" type="checkbox" />
                <label for="checkbox5">
                    Biked
                </label>
                <input id="checkbox6" name="" type="checkbox" />
                <label for="checkbox6">
                    Walked
                </label>
                <input id="checkbox7" name="" type="checkbox" />
                <label for="checkbox7">
                    Other
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q18-19" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q18-19 -->
<div id="Q18-19" data-role="page" data-title="q18-19">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q17" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h4>
            Please read to the participant:
        </h4>
        <h5>
            OK, now I'd like to ask you a few questions about your health...
        </h5>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput14">
                    18. How many times have you been to the emergency room in the past three months?
                </label>
                <input name="" id="textinput14" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput15">
                    19. How many times have you been hospitalized as an inpatient in the past year?
                </label>
                <input name="" id="textinput15" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q20a" data-icon="check" data-iconpos="left" >
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q20a -->
<div id="Q20a" data-role="page" data-title="q20a">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q18-19" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h5>
            20. Do you have now, have you ever had, or has a healthcare provider ever told you that you have any of the following medical conditions?
        </h5>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    a. Kidney disease/End Stage Renal Disease or Dialysis
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
                <input id="radio13" name="" value="radio13" type="radio" />
                <label for="radio13">
                    Refused
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q20n" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#Q20n" data-icon="forward" data-iconpos="left">
            Refuse All Medical Conditions
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q20n -->
<div id="Q20n" data-role="page" data-title="q20n">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q20a" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h2>
            20. DO NOT ASK:
        </h2>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    n. Surveyor, do you observe signs or symptoms of serious physical health conditions?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q21-24" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q21-24 -->
<div id="Q21-24" data-role="page" data-title="q21-24">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q20n" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    21. Have you ever abused drug/alcohol, or been told you do?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
                <input id="radio14" name="" value="radio14" type="radio" />
                <label for="radio14">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    22. Have you consumed alcohol everyday for the past month?
                </legend>
                <input id="radio15" name="" value="radio1" type="radio" />
                <label for="radio15">
                    Yes
                </label>
                <input id="radio16" name="" value="radio16" type="radio" />
                <label for="radio16">
                    No
                </label>
                <input id="radio17" name="" value="radio17" type="radio" />
                <label for="radio17">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    23. Have you ever used injection drugs or shots?
                </legend>
                <input id="radio18" name="" value="radio1" type="radio" />
                <label for="radio18">
                    Yes
                </label>
                <input id="radio19" name="" value="radio19" type="radio" />
                <label for="radio19">
                    No
                </label>
                <input id="radio20" name="" value="radio20" type="radio" />
                <label for="radio20">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    24. Have you ever been treated for drug or alcohol abuse?
                </legend>
                <input id="radio21" name="" value="radio1" type="radio" />
                <label for="radio21">
                    Yes
                </label>
                <input id="radio22" name="" value="radio22" type="radio" />
                <label for="radio22">
                    No
                </label>
                <input id="radio23" name="" value="radio23" type="radio" />
                <label for="radio23">
                    Refused
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q25" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q25 -->
<div id="Q25" data-role="page" data-title="q25">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q21-24" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h2>
            25. DO NOT ASK:
        </h2>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    Surveyor, do you observe signs or symptoms of alcohold or drug abuse?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q26-28" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q26-28 -->
<div id="Q26-28" data-role="page" data-title="q26-28">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q25" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    26. Have you ever been told that you were diagnosed with a mental health issue?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
                <input id="radio14" name="" value="radio14" type="radio" />
                <label for="radio14">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    27. Are you currently/have you ever received treatment for mental health issues?
                </legend>
                <input id="radio15" name="" value="radio1" type="radio" />
                <label for="radio15">
                    Yes
                </label>
                <input id="radio16" name="" value="radio16" type="radio" />
                <label for="radio16">
                    No
                </label>
                <input id="radio17" name="" value="radio17" type="radio" />
                <label for="radio17">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    28. Have you ever been hospitalized for a psychiatric disorder or mental health reasons?
                </legend>
                <input id="radio18" name="" value="radio1" type="radio" />
                <label for="radio18">
                    Yes
                </label>
                <input id="radio19" name="" value="radio19" type="radio" />
                <label for="radio19">
                    No
                </label>
                <input id="radio20" name="" value="radio20" type="radio" />
                <label for="radio20">
                    Refused
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q29" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q29 -->
<div id="Q29" data-role="page" data-title="q29">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q26-28" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h2>
            29. DO NOT ASK:
        </h2>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    Surveyor, do you observe signs or symptoms of severe, persistent mental illness?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q30-32" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q30-32 -->
<div id="Q30-32" data-role="page" data-title="q30-32">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q29" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    30. Have you been the victim of a violent attack since you've become homeless?
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Yes
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    No
                </label>
                <input id="radio14" name="" value="radio14" type="radio" />
                <label for="radio14">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    31. Do you have a permanent physical disability that limits your mobility? [i.e., wheelchair, amputation, unable to climb stairs]?
                </legend>
                <input id="radio15" name="" value="radio1" type="radio" />
                <label for="radio15">
                    Yes
                </label>
                <input id="radio16" name="" value="radio16" type="radio" />
                <label for="radio16">
                    No
                </label>
                <input id="radio17" name="" value="radio17" type="radio" />
                <label for="radio17">
                    Refused
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="horizontal" data-mini="true">
                <legend>
                    32. Have you had a serious brain injury or head trauma that required hospitalization or surgery?
                </legend>
                <input id="radio18" name="" value="radio1" type="radio" />
                <label for="radio18">
                    Yes
                </label>
                <input id="radio19" name="" value="radio19" type="radio" />
                <label for="radio19">
                    No
                </label>
                <input id="radio20" name="" value="radio20" type="radio" />
                <label for="radio20">
                    Refused
                </label>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q33-34" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q33-34 -->
<div id="Q33-34" data-role="page" data-title="q33-34">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q30-32" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    33. In general, would you describe your health as...
                </legend>
                <input id="radio11" name="" value="radio1" type="radio" />
                <label for="radio11">
                    Excellent
                </label>
                <input id="radio12" name="" value="radio12" type="radio" />
                <label for="radio12">
                    Very Good
                </label>
                <input id="radio14" name="" value="radio14" type="radio" />
                <label for="radio14">
                    Good
                </label>
                <input id="radio24" name="" value="radio24" type="radio" />
                <label for="radio24">
                    Fair
                </label>
                <input id="radio25" name="" value="radio25" type="radio" />
                <label for="radio25">
                    Poor
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput16">
                    34. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
                </label>
                <input name="" id="textinput16" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q35-36" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q35-36 -->
<div id="Q35-36" data-role="page" data-title="q35-36">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q33-34" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput16">
                    35. Thinking about your mental health, which includes stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good?
                </label>
                <input name="" id="textinput16" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup">
                <label for="textinput17">
                    36. During the past 30 days, for about how many days did poor physical or mental health prevent you from doing your usual activities, such as self-care, work, or recreation?
                </label>
                <input name="" id="textinput17" placeholder="" value="" type="number" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#Q37" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Q37 -->
<div id="Q37" data-role="page" data-title="q37">
    <div data-theme="a" data-role="header">
        <h3>
            Health
        </h3>
        <a data-role="button" data-rel="back" href="#Q35-36" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <div id="checkboxes2" data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    37. What kind of health insurance do you have, if any? (check all that apply)
                </legend>
                <input id="checkbox8" name="" type="checkbox" />
                <label for="checkbox8">
                    Medicaid
                </label>
                <input id="checkbox9" name="" type="checkbox" />
                <label for="checkbox9">
                    Medicare
                </label>
                <input id="checkbox10" name="" type="checkbox" />
                <label for="checkbox10">
                    VA
                </label>
                <input id="checkbox11" name="" type="checkbox" />
                <label for="checkbox11">
                    Private Insurance
                </label>
                <input id="checkbox12" name="" type="checkbox" />
                <label for="checkbox12">
                    None
                </label>
                <input id="checkbox13" name="" type="checkbox" />
                <label for="checkbox13">
                    Other
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-mini="true">
                <label for="textinput18">
                    If other, please specify:
                </label>
                <input name="" id="textinput18" placeholder="" value="" type="text" />
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#SurveyorSection" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Surveyor Section -->
<div id="SurveyorSection" data-role="page" data-title="surveyorsection">
    <div data-theme="a" data-role="header">
        <h3>
            Surveyor Section
        </h3>
        <a data-role="button" data-rel="back" href="#Q37" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h2>
            DO NOT ASK:
        </h2>
        <div id="checkboxes2" data-role="fieldcontain">
            <fieldset data-role="controlgroup" data-type="vertical" data-mini="true">
                <legend>
                    38. Surveyor, do you observe... (check all that apply)
                </legend>
                <input id="checkbox8" name="" type="checkbox" />
                <label for="checkbox8">
                    signs of not able to meet basic needs? (poor hygiene/clothing, unable to access food on own, no insight on needs)
                </label>
                <input id="checkbox9" name="" type="checkbox" />
                <label for="checkbox9">
                    signs of confusion, disorientation, evidence of dementia, or memory impairment?
                </label>
                <input id="checkbox10" name="" type="checkbox" />
                <label for="checkbox10">
                    signs of problematic social behavior? (responds in angry, profane, obscene, or verbally menacing ways, intimidating, difficulty engaging, yells, screams, or talks to self)
                </label>
            </fieldset>
        </div>
        <div data-role="fieldcontain">
            <fieldset data-role="controlgroup">
                <label for="textarea1">
                    NOTES
                </label>
                <textarea name="" id="textarea1" placeholder="" data-mini="true">
                </textarea>
            </fieldset>
        </div>
        <a data-role="button" data-theme="b" href="#PicturePage" data-icon="check" data-iconpos="left">
            Save and Continue
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>
    
<!-- Picture Page -->
<div id="PicturePage" data-role="page" data-title="picture">
    <div data-theme="a" data-role="header">
        <h3>
            Picture
        </h3>
        <a data-role="button" data-rel="back" href="#SurveyorSection" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h4>
            Read to the participant:
        </h4>
        <h5>
            OK, now I'd like to take your picture. May I do so?
        </h5>
        <a data-role="button" data-theme="b" href="#CompletedPage" data-icon="check" data-iconpos="left">
            Agreed to Take Picture
        </a>
        <a data-role="button" data-theme="a" href="#CompletedPage" data-icon="delete" data-iconpos="left">
            Refused to Take Picture
        </a>
    </div>
</div>
    
<!-- Completed Page -->
<div id="CompletedPage" data-role="page" data-title="completed">
    <div data-theme="a" data-role="header">
        <h3>
            Completed
        </h3>
        <a data-role="button" data-rel="back" href="#PicturePage" data-icon="back" data-iconpos="left" class="ui-btn-left">
            Back
        </a>
        <a data-role="button" href="#help_dialog" data-rel="dialog" data-icon="alert" data-iconpos="left" class="ui-btn-right">
            Help
        </a>
    </div>
    <div data-role="content">
        <h4>
            Identifier: 123-0
        </h4>
        <h4>
            You have completed all questions in the interview.
        </h4>
        <a data-role="button" data-theme="b" href="#login" data-icon="check" data-iconpos="left">
            Submit Responses
        </a>
        <a data-role="button" data-theme="a" href="#login" data-icon="delete" data-iconpos="left">
            Cancel Interview
        </a>
    </div>
</div>

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